EARLY DETECTION
Table 1: 5-year age-standardized relative survival (ASRS %) by country
(VIA) and visual screening with Lugol’s iodine (VILI) can be
and cancer site administered to women between the ages of 30–50 at the
Breast Cervix primary care level if the health centres are equipped with
USA 89.0% 67.8% facilities for pelvic examination and necessary consumables.
China 82.5% 67.0% The primary care practitioners can be readily trained in
Costa Rica 69.6% 53.5%
performing these tests and in interpreting the real time test
Cuba 70.4% 56.3%
results competently in short in-service training courses or by
India 51.6% 46.4%
Philippines 47.4% 37.4% self-learning using manuals, atlases and digital training
Republic of Korea 78.6% 79.2% courses6,7.
Saudi Arabia 64.5% Visual screening tests are the most feasible cervical
Singapore 76.4% 65.7% screening tests that can be administered at the primary care
Thailand 62.8% 60.7%
level, since they do not require a laboratory infrastructure, and
The Gambia 12.5% 21.8%
consumables such as 3–5% dilute acetic acid and Lugol’s
Turkey 77.2% 63.5%
Uganda 45.9% 13.1% iodine can be readily made available in health centres and the
Zimbabwe 57.8% 39.1% test results are interpreted in real time. If a definite
acetowhite area is detected on the cervix 1-minute after the
Source: Sankaranarayanan R et al. Cancer survival in Africa, Asia, the Caribbean and
Central America (SurvCan). IARC Scientific Publications volume 162, Lyon, IARC, 2011. application of acetic acid, VIA testing is positive and if a well-
US National Cancer Institute. Surveillance Epidemiology and End Results (US SEER)
http://surveillance.cancer.gov/statistics/types/survival.html
defined mustard-yellow area appears on the cervix after
application of Lugol’s iodine, VILI testing is positive; VIA- or
to promote early clinical diagnosis and treatment. We plan to VILI-positive women have a high probability of harbouring
cover early diagnosis of other cancer sites at the primary high-grade cervical intraepithelial neoplasia (CIN II or III),
health care level in future editions. which are cervical cancer precursor lesions. Detecting and
effectively treating CIN II and III lesions will result in the
The role of primary health care services in early detection prevention of subsequent invasive cancer among these
Effective cancer early detection efforts at the primary care women. In a setting where there are no resources for directing
level is critically important for the success of clinical early biopsies, colposcopy and histopathology services in secondary
diagnosis efforts, since more than 90% of patient contacts care such as is the case in many sub-Saharan African countries,
within any health care system in the world occur at the VIA- and/or VILI-positive women without clinical features
primary care level in health centres, dispensaries and in the suggestive of invasive cancer may be treated using
offices of general and family practitioners. Millions of people cryotherapy or cold coagulation without further
interact with primary care services on a daily basis, which investigations, in a “screen and treat” mode8,9. The safety,
provides a highly useful platform within health services to acceptability and efficacy of the screen and treat approach in
improve population awareness of common cancers, to preventing CIN has been well documented in less-developed
provide simple screening tests and refer clinically suspect countries8-10. In settings where there is capacity for further
patients for diagnosis and treatment in the secondary or investigations, patients may be referred to secondary care
tertiary care levels as deemed appropriate, provided the facilities where colposcopy, biopsy and further management
doctors, nurses and health workers at the primary care level can be carried out11-13. Women with negative VIA or VILI tests
are knowledgeable and competent to provide these may be advised a repeat screening after 3–5 years.
interventions amidst their routine responsibilities. Prompt In settings where there are facilities for performing Pap
recognition of symptoms and signs that may give an early smear or HPV testing, women above the age of 30 years, who
warning of cancer, however, should also trigger an informed can afford them, may be advised of these tests; those with
and empowered lay individual to seek medical care. Most atypia or worse results on Pap smear or testing positive for
cancers could be detected earlier if the index of suspicion of HPV infection should be referred for investigations and
cancer on the part of primary health care workers was higher, treatment. A single baseline HPV-negative test in women
particularly when providing routine care for persons known above the age of 30 has a high negative predictive value for
to be at high risk for cancer. subsequent cervical neoplasia and thus has an extremely low
risk of invasive cancer or CIN in the next 7–10 years or so14,15.
Early detection of cervical cancer in primary care Women presenting in primary care services may be
Early detection tests such as visual screening with acetic acid routinely asked if they suffer from symptoms such as abnormal
CANCER CONTROL 2013 69